The document summarizes the experience of scaling up HIV treatment in Cameroon through operational research. Cameroon implemented a public health approach to decentralize HIV treatment from central and regional hospitals to district hospitals between 2001-2005. This was supported by standardized treatment guidelines, subsidies for laboratory tests, and a mentorship strategy. Operational research evaluated the impact and found early outcomes were better at district levels, including improved access, quality of care, adherence, and patient perceptions of decentralization. However, challenges remain around sustained drug supply, prevention of unsafe sex, and health worker satisfaction.

1. Scaling-Up HIV Treatment Experience from Cameroon in Operational Research: Main outcomes Sinata Koulla-Shiro MD Chief, Division Of Operations Research, Cameroon, Vice Chair, National AIDS Control Committee and Infectious Disease Service,Yaoundé Central Hospital XVII International AIDS Conference 3-8 August 2008, Mexico City

2. OUTLINE Background The Public Health Approach to Scaling –Up Cameroon Model of scaling-up ARV drug access Operations Research and scaling-up programme Characterisics Main Outcomes Key challenges

3. Background (1/2) 2001: 1 st UN General Assembly Special Session on HIV/AIDS(UNGASS):Targets and member states committment 2004- 2005: Political Committment accompanied by flow of financial ressources(Domestic, multilateral, Bilateral and Private) 2006: UNGASS: Countries agreed toward Universal Access to Comprehensive Prevention, Care and Support by 2010

4. Background (2/2) 2007: Better tools led to Readjustment of figures by UNAIDS and WHO 33 million people live with HIV at global level 2.7 million people newly infected in 2007 9.7 million need treatment in low and middle income countries end 2007 (WHO,UNAIDS,UNICEFprogress report) Unprecedented Momentum of Antiretroviral Treatment in Africa 3 million received ART and >2 million in sub-saharan Africa Access equal or higher among women Adherence equal or greater than un Europe and North America

5. Number of people receiving antiretroviral therapy in low- and middle-income countries, 2002–2007

6. Antiretroviral therapy coverage in sub-Saharan Africa, 2003–2007

7. Women as a percentage of all people receiving antiretroviral therapy versus women as a percentage of all people needing treatment, selected low- and middle-income countries, 2007a 10% 40% 50% 60%

8. The public health approach to scaling up antiretroviral therapy

9. Cameroon Approach to Scaling –Up HIV Drug Access 2001-2002 ART Programme mainly at Central and Regional levels 2003:Standardized guidelines for ART in place 2004:Decentralization to District Hospitals catalysed by WHO « 3by5 » Initiative Strenghthening Health sysytem (procurement, laboratory, task shifting, M/E tools) Subsidies allocated to initial and follow up lab tests 2005:Mentorship Strategy: Tertiary/2ndry hospitals mentor Primary District Hospitals Training and supervision Referral for laboratory tests Referal for complex cases Process accompanied by Operational Research(ANRS)

10. Source: NACC Progress Report

11. National Coverage of Antiretroviral Treatment Sites in Cameroon, 2005 Source: NACC

12. Accredited Treatment centres (ATC) Mentors per province Management Units(MU) Number of MU mentored National Coverage of ART Management Units and Mentors, 2006 5 12 4 4 7 5 4 6 5 5

13. Figure 6 : Evolution du nombre des malades sous ARV au Cameroun: juillet 2005 à décembre 2007 Source: NACC, 2008

15. Adult First Line ARV Regimens used in Cameroon, 2008 Source: NACC Progress Report, April 2008

16. Source: NACC Progress Report, April 2008 First Line ARV Regimens used for Children in Cameroon, 2008

19. Components of Scaling-Up Operations Research 4 Complementary Projects ANRS 12110 trial Stratall,Charles Kouanfack ANRS 12120: Problematic of Access to Treatment: Advances, Limits and perspectives of decentralization, F. Eboko ANRS 12108: Scaling –Up and Procurement of Drugs and Biological Tools, B. Coriat/M.J Essi (Presented yesteday) ANRS 12116: Impact of Access to HIV Management and living conditions of Patients, J. P Moatti/SC Abega

20. The Eval ANRS 12116 Study Primary Objective: Evaluate the quality of care of patients on ART About 3000 patients; 26 Health care Facilities;Urban and rural Variables studied Medical Effeciency: Sociobehavioral Factors Adherence to treatment Health Related Quality of life Sociodemograhic and economic factors Cost effectiveness Equity Impact on risky behaviour: Impact on Health System KAP

21. Outcome of decentralization Early outcomes better at district level : Early access to treatment HIV service performance HRQL especially mental Adherence to therapy Task shifting Positive role of associations of PLWH Patients perception in favour of decentralization Financial accessibility of HIV services remains a major barrier Other Challenges of ART scale-Up ARV drug stocks out unsafe sex common among PLWH on ART and erronous beliefs that ART efficacy prevents HIV transmission is a major determinant Unfelt impact of Community relay workers: need revisiting Health workers dissatisfied with working conditions Sustained efforts on HIV Prevention

22. Impact of 3 scenarios on HIV infection in sub-saharan Africa, 2003-2020